Lawless-Pyne, Timothy Paul

CORONERS COURT OF QUEENSLAND FINDINGS OF INQUEST CITATION: Inquest into the death of Timothy Paul

LAWLESS-PYNE TITLE OF COURT: Coroners Court JURISDICTION: Brisbane FILE NO(s): 2016/3850 DELIVERED ON: 20 June 2019 DELIVERED AT: Brisbane HEARING DATE(s): 20 June 2019 FINDINGS OF: Terry Ryan, State Coroner CATCHWORDS: Coroners: inquest, death in custody, natural causes.

REPRESENTATION: Counsel Assisting: Ms Sarah Lane Queensland Corrective Services: Ms Aggie Honkisz Metro South Hospital & Health Service: Ms Danielle Blonde

Contents

Introduction

1. Timothy Lawless-Pyne was 57 years of age when he died in palliative care at the Princess Alexandra Hospital (PAH) Secure Unit (SU) late on the evening of 14 September 2016. Mr Lawless-Pyne was an inmate at the Woodford Correctional Centre (WCC) where he was serving a term of life imprisonment for murder. He had liver cancer and, on 7 September 2016, was admitted to the PAH with intense pain from secondary bone cancer. Mr Lawless-Pyne died of natural causes from terminal liver cancer, which developed as a result of cirrhosis of the liver and Hepatitis-C infection.

Police investigation

2. An investigation into the circumstances leading to Mr Lawless-Pyne’s death was overseen by Detective Senior Constable Amanda Watt from the Queensland Police Service (QPS) Corrective Services Investigation Unit (CSIU). I am satisfied that the investigation was suitably comprehensive in the circumstances.

3. After being notified of Mr Lawless-Pyne’s death, CSIU officers attended the PAH on 14 September 2016. Mr Lawless-Pyne’s correctional records and his medical files from WCC and the PAH were obtained.

4. The CSIU investigation was informed by statements from relevant custodial correctional officers and nursing staff at the PAH, and medical officers at the PAH, including Mr Lawless-Pyne’s treating gastroenterologist. These statements were tendered at the inquest.

5. On the basis of the evidence obtained Detective Senior Constable Watt provided a report dated 3 January 2017 which contained the following conclusions:

6. At the time of the decease’s incarceration he was known to have suffered from Hepatitis C, chronic liver disease, cirrhosis of the liver and chronic backache.

7. The deceased had been receiving medical treatment at the PAH throughout his time of incarceration. In September 2016 the deceased’s medical condition became non-responsive to treatment and was considered to be terminal.

8. The deceased was always afforded medical care for his illness during his time of incarceration within Queensland Correctional Facilities.

9. QCS staff and Queensland Police Service Officers correctly followed death in custody protocols.

5. There are no suspicious circumstances surrounding the death of the deceased.

6. This death is a non-suspicious death.1 1 Exhibit A5, p 7.

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CFMU Review

6. At the request of the Coroners Court, Dr Katharine Robinson, forensic medical officer, Clinical Forensic Medicine Unit (CFMU) examined the autopsy report and Mr Lawless-Pyne’s medical records. Dr Robinson was asked to comment on the health care which was provided to Mr LawlessPyne in the twelve months leading up to his death.

7. Dr Robinson had no concerns regarding the quality of the care provided to Mr Lawless-Pyne at the PAH or the WCC. She noted that Mr Lawless-Pyne received aggressive treatment of his malignancy and all available treatment options were considered throughout his illness. He had been followed closely by the Gastroenterology and Hepatology team at the PAH.

8. Dr Robinson noted that as medical complications developed as Mr LawlessPyne’s disease was progressing, he was transferred from the correctional facility to the PAH in a timely fashion and had a number of interventions to manage his tumour and the complications arising from it (including TACE and variceal ligation). She said that Mr Lawless-Pyne deteriorated fairly rapidly in September 2016, when it had been recognised that he had advanced hepatocellular carcinoma, which was both totally invasive and associated with bony metastases.

9. Dr Robinson considered that Mr Lawless-Pyne’s timely admission to the PAH in September 2016 for investigation of the bone pain in his clavicle meant that he was well-placed to receive end-of-life care after his sudden deterioration. She concluded that “the care received by Mr Lawless-Pyne from the time of his diagnosis with hepatocellular carcinoma until his death was of a very high standard”.2 The Inquest

10. As Mr Lawless-Pyne died in custody, an inquest was required by s 27 of the Coroners Act 2003. The inquest was held on 20 June 2019. All of the statements, medical records and material gathered during the investigation into Mr Lawless-Pyne’s death were tendered to the court. Counsel Assisting proceeded immediately to submissions in lieu of any oral testimony being heard.

The Evidence Personal circumstances and correctional history

11. Mr Lawless-Pyne was born on 30 April 1959 in Gayndah, Queensland. He was survived by his mother, Moira, his sister, Margot, and two brothers.3 I extend my condolences to Mr Lawless-Pyne’s family.

2 Exhibit B5, pp 6 - 7.

3 Exhibit B2, paras 4 – 8.

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12. Mr Lawless-Pyne was reported to have developed a drug habit when he was aged 16 years. He was a heroin user, and also used other drugs including marijuana and alcohol. His sister said that in his mid-twenties, Mr LawlessPyne was diagnosed with a marijuana induced bipolar disorder.4

13. Mr Lawless-Pyne’s drug taking led him into contact with the criminal justice system. In 1978, when he was aged 19, he was convicted of cultivating and possessing a prohibited plant. From that time on, Mr Lawless-Pyne engaged in offending behaviour on a regular basis, with intermittent periods of imprisonment. He was first sentenced to imprisonment in 1981 when he received nine months for the offences of grievous bodily harm and wounding. Mr Lawless-Pyne’s criminal history shows that the seriousness of his offending escalated over the course of his life, culminating in a sentence of life imprisonment for murder on 30 April 1998, which was his fourth period of incarceration in adult prison. He later committed two further offences in prison: an assault occasioning bodily harm in 2002, and possessing a prohibited article in 2004.5 Medical history

14. In 2003, Mr Lawless Pyne was admitted to the PAHSU and was diagnosed with chronic hepatitis C infection. Mr Lawless-Pyne would later tell his doctors that, prior to his most recent imprisonment, he was injecting 4 grams of heroin and drinking 1.5 litres of rum each day.6 The hepatitis C infection, along with his previous excessive alcohol consumption, led to the development of liver disease. In 2005, a liver biopsy confirmed that Mr Lawless-Pyne had developed cirrhosis of the liver. After this diagnosis, Mr Lawless-Pyne was admitted to the PAH every six months for endoscopies and ultrasounds so that his doctors could screen for complications arising from the cirrhosis.

15. In 2008, Mr Lawless-Pyne was undertaking an undergraduate degree in Biological Science from prison. Around this time he was also suffering severe back and neck pain due to osteoarthritic changes in his vertebrae. It was difficult for doctors to prescribe pain relief for Mr Lawless-Pyne as many analgesics were ineffective, or would have adversely affected his liver.7

16. In 2009, Mr Lawless-Pyne was given a course of antiviral therapy for the hepatitis C, but the infection did not respond to this treatment. Mr LawlessPyne’s treating doctors continued their regular testing for complications. In 2014, an ultrasound showed two small lesions on Mr Lawless-Pyne’s liver.

The lesions were not, at that stage, big enough to be considered hepatocellular carcinomas (HCC), but it was possible that the lesions could grow and/or that others could form. At that time, Mr Lawless-Pyne’s treating doctor in the PAHSU was Dr Graeme MacDonald. Dr MacDonald ordered that the next scan take place in three rather than six months. That scan 4 Exhibit B2, paras 10 - 11.

5 Exhibit C1.

6 Exhibit D2.15, p 218.

7 Exhibit D2.15, p 208, 218, and 235.

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showed that one of the lesions had grown, and a subsequent MRI suggested that the lesions were “almost certainly HCC”.8

17. Mr Lawless-Pyne had kept in contact with his sister, Ms Perkins, by letter from prison. Ms Perkins recalls that in around 2014, Mr Lawless-Pyne advised her that he had developed liver cancer and that the treatment he was undergoing was no longer effective.9

18. Mr Lawless-Pyne was assessed for suitability for surgery, radiotherapy or chemotherapy. His liver was not considered healthy enough to tolerate surgery, and the lesions were located in an area that would be difficult to target with radiotherapy.

19. Mr Lawless-Pyne proceeded with chemotherapy by way of transarterial chemoembolization (TACE), and was given his first treatment in March

20. TACE is a therapy which is used to prolong life, but cannot cure HCC.

The TACE therapy appeared to be successful for a while, but in August 2015 Mr Lawless-Pyne suffered the first of a number of oesophageal variceal haemorrhages (bleeding from veins in his lower oesophagus), a known complication of advanced liver disease. He also began having issues with other complications, including hepatic encephalopathy (altered level of consciousness due to liver disease) and thrombocytopaenia (low platelet count leading to bleeding).10

20. Dr MacDonald continued Mr Lawless-Pyne’s three monthly scans, and in March 2016 an MRI showed that his HCC had progressed to the point that he had lesions in every liver segment. A second round of TACE in April 2016 did not achieve good results.11

21. In June 2016, Mr Lawless-Pyne, with the assistance of the Prisoners Legal Service, was in the process of filing an Exceptional Circumstances application for parole given the advanced nature of his condition. His application was supported by Dr Rajendra Prakash, a Visiting Medical Officer (VMO) at WCC who had treated Mr Lawless-Pyne since 2008.12

22. In July 2016, scans showed that Mr Lawless-Pyne’s HCC had dramatically progressed, and that the lesions had extended into the left portal vein of his liver. His treating team considered that the HCC had advanced to the point that no further therapy was possible.13

23. In August 2016, Dr Prakash discussed with Mr Lawless-Pyne the fact that he had advanced HCC and various complications arising from that condition. Dr Prakash advised Mr Lawless-Pyne to consider making 8 Exhibit B1, pp 1 - 2.

9 Exhibit B2, para 16.

10 Exhibit B1, p 2.

11 Exhibit B1, p 2.

12 Exhibit D1, pp 167 – 168, 171 - 172.

13 Exhibit B5, paras 22 - 23.

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arrangements regarding his will, power of attorney, acute resuscitation plan and advanced care directives. Dr Prakash said that Mr Lawless-Pyne told him that he “believed that he would be released from prison soon, and preferred to make those arrangements after release from prison”.14

24. Ms Perkins recalled Mr Lawless-Pyne writing in 2016 that his treatment had become ineffective and would be ceased. He informed her that the cancer had spread to his spleen and bones.15

25. By September 2016, Mr Lawless-Pyne was experiencing ongoing pain in his right upper abdomen, as well as pain in his left collarbone. He was admitted to the PAHSU on 7 September for a bone scan. The scan showed that Mr Lawless-Pyne was experiencing pain in his collar bone because he had developed a tumour in the bone. On 9 September 2016, doctors discussed Mr Lawless-Pyne’s condition with him, and advised him that the cancer was advanced and incurable. Mr Lawless-Pyne was advised to make arrangements regarding his will and other affairs.16 That day Mr LawlessPyne called his sister and told her that the doctors at the PAHSU had said that he had four days to live.17

26. Mr Lawless-Pyne’s treating team referred him to palliative care, where the focus was to manage his pain levels and ensure that he was comfortable. 18 Mr Lawless-Pyne was reviewed by the Radiation Oncology specialists, and plans were made for him to undergo palliative radiotherapy on 14 September 2016.19

27. On 10 September 2016, Ms Perkins visited Mr Lawless-Pyne along with their mother. Ms Perkins said that Mr Lawless Pyne “appeared to be lucid and calm and accepting of his situation” and that he “had a wonderful rapport with the nursing staff”.20 14 Exhibit B3, para 19.

15 Exhibit B2, para 17.

16 Exhibit D2.12, pp 55 - 56.

17 Exhibit B1, p 2; Exhibit B2 – paras 18 – 19; and Exhibit B5, para 24.

18 Exhibit B5, paras 26 - 28.

19 Exhibit B1, p 2.

20 Exhibit B2, paras 20 – 21.

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Circumstances of the death

28. On 13 September 2016, Mr Lawless-Pyne’s condition deteriorated. He suffered rectal bleeding in the morning and, later in the day, had blood in his vomit. His blood pressure dropped and he began to lose consciousness.21

29. Hospital staff contacted Ms Perkins and advised her that Mr Lawless-Pyne was very unwell. At around 1:00pm that day, Ms Perkins visited the hospital with her mother. When they went to Mr Lawless-Pyne’s room he was unconscious. Dr MacDonald discussed Mr Lawless-Pyne’s condition with his family, and advised that there was nothing more they could do “apart from keep [Mr Lawless-Pyne] comfortable and pain free”.22

30. On 14 September 2016, Mr Lawless-Pyne was still unresponsive. Ms Perkins and her mother spent the day at his bedside and left in the afternoon.23 Corrective Services Officer (CSO) Storm Wilson began his shift outside Mr Lawless-Pyne’s room that afternoon at 5:30pm. CSO Wilson noted that Mr Lawless-Pyne was unconscious but breathing and observed nursing staff entering regularly to conduct observations. Just before 10:25pm, CSO Wilson noticed a change in Mr Lawless-Pyne’s breathing, and immediately notified nursing staff. While the nursing staff were attending to Mr Lawless-Pyne, CSO Wilson heard Mr Lawless-Pyne’s breathing slow and then stop.24

31. At 1:00am on 15 September 2016 Dr Pirathaban Sivabalan attended Mr Lawless-Pyne and certified that he had passed away at 10:25pm on 14 September 2016.25

32. After Mr Lawless-Pyne passed away, his mother wrote a letter to the staff at the PAHSU thanking them “for the wonderful care that they gave” Mr Lawless-Pyne over the years and particularly in his final days”.26 Autopsy

33. On 16 September 2016, Senior Forensic Pathologist, Dr Nathan Milne conducted an autopsy consisting of an external examination of the body, blood tests, a whole body CT scan and a review of Mr Lawless-Pyne’s medical records. The CT scan showed a tumour on Mr Lawless-Pyne’s left clavicle, and changes in the liver consistent with Mr Lawless-Pyne’s diagnoses of Hepatitis C, cirrhosis and liver cancer.

21 Exhibit B5, para 27.

22 Exhibit B2, para 17.

23 Exhibit B2, para 25.

24 Exhibit B4, paras 4 – 10 and Exhibit B4.1, p 6.

25 Exhibit D2.12, p 35.

26 Exhibit B2, para 29.

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34. Dr Milne concluded that the cause of death was bleeding within the gastrointestinal tract, which was clinically considered most likely to be due to Mr Lawless-Pyne’s known oesophageal varices. Dr Milne noted that the varices had developed as a complication of his liver disease which included cirrhosis and advanced hepatocellular carcinoma, and that his cirrhosis had initially been due to an infection with hepatitis C virus.27

35. Dr Milne concluded that the cause of death was: 1(a) Bleeding oesophageal varices, due to, or as a consequence of, 1(b) Cirrhosis and metastatic hepatocellular carcinoma, due to, or as a consequence of, 1(c) Hepatitis C virus infection.28

36. Toxicology results were negative for alcohol and illicit drugs, and showed only therapeutic quantities of the medications that Mr Lawless-Pyne had been prescribed or that were administered to him at the PAHSU.29 Dr Milne noted that the quantity of morphine detected was at a potentially lethal level, but that this was “not unexpected in a palliative setting”.30 Conclusions

37. Mr Lawless-Pyne’s death was the subject of a police investigation. That investigation has been considered by me and I accept that the death was from natural causes with no suspicious circumstances associated with it.

38. On the basis of Dr Robinson’s opinion, I am satisfied that Mr Lawless-Pyne was given appropriate medical care by staff at WCC and at the PAH while he was admitted there. His death could not reasonably have been prevented.

39. It is a recognised principle that the health care provided to prisoners should not be off a lesser standard than that provided to other members of the community. The evidence tendered at the inquest established the adequacy of the medical care provided to Mr Lawless-Pyne when measured against this benchmark.

40. In considering this matter, I also had the benefit of written submissions from QCS, who advised that they agreed with the findings of Detective Senior Constable Watt and the opinion of Dr Robinson.

27 Exhibit A4, p 5.

28 Exhibit A4 – Autopsy Report, p 5.

29 Exhibit A3 – Toxicology Certificate 30 Exhibit A4 – Autopsy Report, p 5.

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Findings

41. I am required to find, as far as is possible, the medical cause of death, who the deceased person was and when, where and how he came by his death.

After considering all of the evidence, including the material contained in the exhibits, I am able to make the following findings: Identity of the deceased - Timothy Lawless-Pyne How he died - Mr Lawless-Pyne was serving a life sentence for murder and had been in custody for nearly 19 years.

From 2003, he was known to have hepatitis C, and chronic liver disease as a consequence of hepatitis C and alcohol consumption. He was transferred from the Woodford Correctional Centre to the Princess Alexandra Hospital Secure Unit seven days before his death in response to chronic pain associated with multifocal hepatocellular carcinoma. He was given palliative treatment and comfort care after consultation with his family.

Place of death - Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba in the State of Queensland.

Date of death - 14 September 2016.

Cause of death - The medical cause of death was: 1(a) Bleeding oesophageal varices, due to, or as a consequence of, 1(b) Cirrhosis and metastatic hepatocellular carcinoma, due to, or as a consequence of, 1(c) Hepatitis C virus infection Findings of the inquest into the death of Timothy Paul Lawless-Pyne Page 8 of 9

Comments and recommendations

42. The Coroners Act 2003 enables a coroner to comment on anything connected with a death that relates to public health or safety, the administration of justice or ways to prevent deaths from happening in similar circumstances in the future.

43. In the circumstances, I accept that there are no comments or recommendations to be made that would assist in preventing similar deaths in future, or that otherwise relate to public health or safety or the administration of justice.

44. I close the inquest.

Terry Ryan State Coroner 20 June 2019 Findings of the inquest into the death of Timothy Paul Lawless-Pyne Page 9 of 9